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Abstract

Background

The evaluation of all potential sources of low skilled maternal care utilization is
crucial for Ethiopia. Previous studies have largely disregarded the contribution of
different levels. This study was planned to assess the effect of individual, communal,
and health facility characteristics in the utilization of antenatal, delivery, and
postnatal care by a skilled provider.

Methods

A linked facility and population-based survey was conducted over three months (January
- March 2012) in twelve “kebeles” of North Gondar Zone, Amhara Region. A total of
1668 women who had births in the year preceding the survey were selected for analysis.
Using a multilevel modelling, we examined the effect of cluster variation and a number
of individual, communal (kebele), and facility-related variables for skilled maternal
care utilization.

Result

About 32.3%, 13.8% and 6.3% of the women had the chance to get skilled providers for
their antenatal, delivery and postnatal care, respectively. A significant heterogeneity
was observed among clusters for each indicator of skilled maternal care utilization.
At the individual level, variables related to awareness and perceptions were found
to be much more relevant for skilled maternal service utilization. Preference for
skilled providers and previous experience of antenatal care were consistently strong
predictors of all indicators of skilled maternal health care utilizations. Birth order,
maternal education, and awareness about health facilities to get skilled professionals
were consistently strong predictors of skilled antenatal and delivery care use. Communal
factors were relevant for both delivery and postnatal care, whereas the characteristics
of a health facility were more relevant for use of skilled delivery care than other
maternity services.

Conclusion

Factors operating at individual and “kebele” levels play a significant role in determining
utilization of skilled maternal health services. Interventions to create better community
awareness and perception about skilled providers and their care, and ensuring the
seamless performance of health care facilities have been considered crucial to improve
skilled maternal services in the study area. Such interventions should target underprivileged
women.

Keywords:

Skilled maternal care; Linked survey; Multilevel analysis

Background

In Ethiopia, maternal health has received attention for the last two decades. Currently,
reducing maternal mortality is one of the goals of the Health Service Development
Program of the country. Maternal and newborn health is also among the six priority
areas in the reproductive health strategy [1]. Based on ecological and historical evidences observed in European and Asian countries,
health professionals with midwifery skill were considered the key factors to decrease
maternal mortality. The low maternal mortality rates reported by the Netherlands,
Norway, and Sweden in the early 20th century were believed to have been the result
of an extensive collaboration between physicians and highly competent, locally available
midwives [2]. Similarly, Malaysia, Sri Lanka and Thailand halved their maternal mortality ratios
within ten years by increasing the number of midwives in the 1950s and 1960s [3].

At the moment, many countries including Ethiopia are working to meet the WHO recommendation
of having skilled attendance for all births [4]. According to the recent 2011 Ethiopian Demographic and Health Survey (EDHS) report,
only 34%, 10% and 6% of the women had Antenatal Care (ANC), delivery, and postnatal
care by skilled providers respectively [5]. Maternal mortality has also not changed from its previous level where maternal mortality
ratio was 673 per 100,000 live births in the 2005 EDHS report [6], and it was 676 per 100,000 live births in the 2011 EDHS report [5].

Skilled maternal care refers to maternity services (antenatal, delivery, and postnatal
care) by a health professional with midwifery skill that can be provided at different
levels (home, health centers or hospitals). In order to provide such skilled maternal
care, we need to have an enabling environment and skilled providers. An enabling environment
include; functional health facilities and a reliable referral system to link the different
levels, awareness and readiness of the community for utilizing skilled care as well
as supporting the policy and political commitment [4]. Health professionals who have been educated and trained to proficiency in the skills
needed to manage normal pregnancies, childbirth and the immediate postnatal period,
and in the identification, management or referral of complications are categorized
as skilled care providers [7,8]. In the study, skilled providers include midwives, nurses, health officers and doctors.

There are several factors influencing skilled maternal health care utilization within
the dimensions of skilled maternal care definition. The factors operate their impact
at different levels. Review of the global literature indicates that these factors
can be classified as 1) individual and household level 2) communal and health facility
level and 3) national or state level.

At the individual and household level maternal education, parity, residence, awareness
and perceptions related to the risks of pregnancy and skilled maternal services, previous
experiences, women’s decision-making power, and household wealth are some of the known
variables.

At the health facility level the availability, readiness, and quality of services
as well as the type, competence and caring behavior of providers are very important
for maternal services. However, in many developing countries health facilities are
not performing the expected functions according to their level [9]. Furthermore, there is a huge gap in the competence of health workers categorized
as skilled providers [8,10]. Pre-service training is also not a guarantee. It is recommended that maternity care
providers need to receive refresher training or updates in midwifery every three to
five years [11].

Some studies identified community and state level factors using multilevel analysis.
A study in Vietnam reported that the presence of low education coverage, geographical
isolation, and high poverty rate in the community reduce access to skilled maternal
services [12]. Evidences from Nigeria also showed that urban residence and the availability of
community media significantly increased maternal service utilization [13]. At the policy level, resource investments in the main system components of health
programs raised the level of maternal service utilizations [14]. The significant effect of government health expenditure in improving the utilization
of skilled maternal service was also observed in other studies [15,16].

Studies in Ethiopia have serious limitations in evaluating the determinants of skilled
maternal care utilization. The studies provided evidence based on the evaluation of
either user or facility related determinants. Addressing only one of these categories
is likely to present a very incomplete picture of the evaluation of determinants affecting
maternal service utilization. In addition, the nesting effects of different levels
are usually not controlled during analysis. Therefore, appropriate methodology is
required for a more comprehensive and accurate analysis. As a result, all potential
sources of poor skilled maternal care utilization can be evaluated to design maternal
service strategies at different levels. This study was planned to assess the effect
of individual, household, communal and health facility characteristics in the utilization
of antenatal, delivery, and postnatal care by a skilled provider.

Methods

Study design and area

A linked facility and population-based survey i.e. a facility survey linked to population
based survey sample areas was conducted over three months (January - March 2012) in
North Gondar Zone. The two surveys were conducted concurrently to analyze all potential
factors operating at different levels (individual and community levels) simultaneously.
The use of linked survey is also considered as stronger approach to analyze causality
in non-experimental studies [17].

North Gondar is one of the 11 zones of the Amhara Regional State located in northwest
Ethiopia. It has 22 districts. The zonal center, Gondar town, is located 735 kilometer
from Addis Ababa. At the time of the study, more than three million individuals were
living in the zone. About 84.1% of its inhabitants were rural dwellers [18]. North Gondar, the largest zone of the region, is known for its difficult topography.

Study population and sampling

Women who had births in the year preceding the survey were included in the study.
A multistage sampling technique was applied to select the study population. Initially,
six districts of the zone namely Dembia, Lay Armachiho, West Belessa, Metema, Debark
and Dabat were selected. Then a total of twelve clusters or kebeles (two kebeles per
district) were selected randomly. The ‘kebeles’ are the lowest administrative units
with a size of about 1000 households (5000 population). All eligible women found in
the selected cluster were studied. Accordingly, 1730 women were identified for interview.

The adequacy of the sample size was checked based on differences in frequency of important
exposure variables among users and non-users at the time of proposal development.
Epi Info StatCalc software was used for the calculations by assuming a 95% confidence
level and 80% power with a 1:3 ratio of users and non-users.

In order to have a linked data, basic essential obstetric care facilities (health
centers) utilized by the kebele population were selected for the facility based survey.
For each cluster (kebele), one basic essential obstetric care facility was studied
and linked.

Data collection

All health facilities serving the study population were assessed with regard to the
number, training and competency of obstetric staff; services offered; signal functions;
physical infrastructure; and availability, adequacy and functional status of supplies
and other essential equipment for maternal services. The basic signal functions include
parenteral antibiotics, anticonvulsants and oxytocics, and the procedures for manual
removal of the placenta, removal of retained uterine products, and assisted vaginal
delivery. During the population based survey information about kebele (cluster) characteristics,
socio-demographic characteristics, awareness, perceptions and experiences related
to the women’s use of skilled maternal care services were collected.

For the population based survey, a total of 36 qualified data collectors and supervisors
(2 data collectors and 1 supervisor for each kebele) were trained and deployed. The
interviews were conducted using the local language (Amharic) after the questionnaire
was pretested for cultural appropriateness and clarity. For the facility-based survey,
14 health professionals who had work experience were recruited.

Data analysis and modeling

After appropriate coding, the data were entered using Epi Info version 3.5.3 software
and exported to STATA version 11 software for analysis. Uses of maternal services
(antenatal, delivery and postnatal care) by skilled providers were the dependent variables.
The predictors of each of these indicators were assessed separately using a multilevel
binary logistic regression.

The rationales for using a multilevel modeling were the following. Firstly, the utilization
patterns of maternal health services are influenced by the characteristics of different
levels (individuals, community, and health facilities). Analyzing variables from different
levels at one single common level using the standard binary logistic regression model
leads to bias (loss of power or Type I error). This approach also suffers from a problem
of analysis at the inappropriate level (atomistic or ecological fallacy). Multilevel
models allow us to consider the individual level and the group level in the same analysis,
rather than having to choose one or the other. Secondly, due to the multistage cluster
sampling procedure, individual women were nested within kebeles; hence, the likelihood
of women seeking maternal health services is likely to be correlated to the kebele
members. The assumption of independence among individuals within the same cluster
and the assumption of equal variance across clusters are violated in the case of nested
data. Hence, the multilevel analysis is the appropriate method for such cases.

Using a two-level binary logistic regression modelling, we examined the effect of
a number of individual, community, and facility variables. During analysis, the characteristics
of women and household were taken as individual level (level-1), and characteristics
of the kebeles (including characteristics of their health centers) were treated as
level-2 (Table 1). For each of the three dependent variables, we estimated two models: intercept-only
model; an empty model that contains no covariates, and a full model that included
individual and kebele level variables. The full model was a random slopes model for
ANC and a random intercept model for delivery and postnatal care.

Table 1.Description and measurement of variables included in the models, North Gondar, 2012

Assume the binary responses Yij depend on individual-level explanatory variable Xij and group-level explanatory variable Zj. If deviation from the average intercept and slope due to cluster (level-2) effect
are represented by u0j and u1j, the two models are given in the following way.

The intercept-only model allows us to evaluate the extent of the cluster variation
influencing maternal service utilization of women. The intra-class correlation coefficient
(Rho) was calculated to evaluate whether the variation in the scores is primarily
within or between clusters. In logistic distribution, level-1 residual variance, εij, is standardized and fixed with a mean of zero and variance = π2/3. Therefore, for a two-level logistic random intercept model with an intercept variance
of σ2u0, the intra-class correlation coefficient (Rho) is given by .

Ethical considerations

Before the commencement of the study, ethical clearance was obtained from the Institutional
Review Board of the College of Health Sciences, Addis Ababa University. Then permission
letters from officials of districts and health institutions were processed before
starting data collection. During data collection, study participants were asked for
consent and were signed written agreements on consent forms. They were informed to
interrupt the interview on desire. To ensure confidentiality, names were not used,
instead code numbers were assigned to depict the results and the questionnaires were
kept locked.

Results

A total of 1730 women were interviewed. For analysis, 1668 women were considered because
some 62 copies of questionnaire were excluded during the data cleaning process due
to incompleteness and inconsistent values. Majority of the study subjects was Orthodox
Christians (93.7%), Amhara by ethnicity (92.7%) and currently married (92.7%). At
the time of their last birth, about 73.3% were between 20–34 years, 5.5% were teenagers
(less than 20 years) and 21.2% were elderly gravid (35 years and above). The mean
age was 28.2 ± 6.6 years, with a range of 16–51 years. The majority of the mothers
(71%) and their husbands (63.4%) had no formal education (Table 2).

About 32.3% (95% CI, 30.0%, 34.5%), 13.8% (95% CI, 12.2%, 15.5%) and 6.3% (95% CI,
5.1% to 7.5%) of women used antenatal, delivery and postnatal care by skilled providers,
respectively. The bivariate analysis indicated that use of all indicators of skilled
maternal services appeared to increase significantly with educational status of women
and their husbands. Moreover, higher wealth quintiles, awareness of risk of pregnancy,
preference for skilled provider, awareness about health facilities to get skilled
professionals and previous experience of antenatal care showed a significant and positive
association while higher birth order, and unwanted pregnancy showed a negative association
in all maternal service indicators (Table 2).

The multilevel analysis was started from the intercept-only model to test the null
hypothesis that there is no variation in maternal health services utilization between
clusters (kebeles) and to decide in evaluation of the random effects at the community
level. The results presented in Table 3 indicated that considerable heterogeneity between kebeles was observed for each indicator
of skilled maternal care utilization. In all the three indicators, use of service
is clustered significantly by kebele. The intra-class correlation in the empty model
for antenatal, delivery and postnatal care by skilled provider indicated that 31%,
12%, and 25% of the total variance in use of the services was attributable to the
differences across kebeles (Table 3).

Table 3.Parameter coefficients of the intercept-only model in using skilled maternal care,
North Gondar, 2012

Antenatal care by a skilled provider

Maternal education, preference for skilled provider, awareness about health facilities
to get skilled professionals and previous experience of antenatal care were strong
individual level predictors of the recent antenatal care by a skilled provider. The
predictor ‘birth order’ indicates that women tend to use antenatal care by a skilled
provider if their birth is their first time, and a small but significant difference
was observed compared with those women with four or five births. The odds ratio indicates
that use of antenatal services initially decreases with birth order up to the third
category and increases thereafter.

Antenatal care by a skilled provider increases steadily with education so that women
with secondary and above education were 68% more likely to use service as their counterparts
with no education. Women who have had at least one antenatal care in previous pregnancies
were about three times more likely to use skilled antenatal care for their recent
pregnancy. Similarly, women who preferred health professionals for their maternity
care and have awareness about health facilities to get skilled professionals significantly
use skilled antenatal care compared with their counterparts.

The study further showed that communal level variables included in the model were
not significant predictors of skilled antenatal services utilization.

Finally, a substantial proportion of the between kebele variance was explained by
this model given the between kebele variation has been reduced from 1.52 to 0.76,
a 50% reduction in unexplained variance between kebele ANC utilization. However, community
level random effects are significant; the residual intra-class correlation is still
appreciably large, indicating that even after controlling for individual, communal
(kebele) level factors, there is still a considerable clustering of antenatal service
utilization at the community (kebele) level. The between kebele variance of slopes
indicated that the two variables, ANC in the previous pregnancies and preference for
skilled providers, significantly varied across kebeles. That means, the relationships
between these variables and ANC use by women were different for different kebeles
(dependent on the proportion of ANC users in the kebeles) (Table 4).

Table 4.Results of the multilevel analysis by predictors of skilled maternity care, North
Gondar, 2012

Delivery care by a skilled provider

The significant individual level variables that predict use of delivery care by a
skilled provider include; birth order, maternal education, preference for skilled
provider, awareness about health facilities to get skilled professionals, experience
of antenatal care for previous pregnancies and skilled antenatal care for the recent
pregnancy. Women who had births for the first time were more likely to use skilled
birth attendance compared with any of the birth order categories, and the difference
was statistically significant in all comparisons. As we observed with the use of antenatal
care, skilled attendance at birth increases significantly with secondary education.
Women having at least one antenatal care in previous pregnancies or skilled antenatal
care in their recent pregnancy were about two times more likely to have birth attendance
by a skilled provider. Similar to the antenatal care service, women who preferred
health professionals for their maternity care and have awareness about health facilities
to get skilled professionals used significantly more delivery care by a skilled provider
compared with their counter parts.

Three predictor variables from the second level, that is, source of income, signal
function and payment requirements during delivery were significantly associated with
skilled attendance at birth. Women who belonged to communities with mixed (farming
and trading) source of income used skilled attendance 64% higher than those who belonged
to only farming as the main source of income. The presence of all the six signal functions
in the nearby basic essential obstetric care facility (health center) increased skilled
attendance rate about two times compared to those health centers with at least one
function is missing. By contrast, presence of payment requirements during delivery
reduced utilization of skilled attendance by 47%.

The random part of this model indicated that almost all of the between kebele variance
was explained by the included variables in the model. The model fitness was also improved
significantly (Table 4).

Postnatal care by skilled attendant

Three predictor variables, two from the individual level and one from the communal
level significantly associated with postnatal care by a skilled provider. At the individual
level, women who preferred skilled provider for their maternity care, and women who
had experience of at least one antenatal care for their previous pregnancies used
a skilled postnatal care more likely compared with those who did not have such characters.

At the communal level, the odds of postnatal care by a skilled provider significantly
increased among women belonging to communities who had mixed (farming and trading)
source of income compared with those belonging to only farming as the main source
of income.

Like that of the skilled attendance at birth, the random part of the model indicated
that almost all of the between kebele variance in the use of skilled postnatal care
was explained by the variables in the model (Table 4).

Discussion

Using a linked population and facility based survey and appropriate modeling framework,
this study assessed the effect of individual, household, communal and health facility
characteristics in utilization of antenatal, delivery, and postnatal care by a skilled
provider. The results suggest that utilization of skilled maternal care by individual
women is very low in the study area. The finding is consistent with the recent EDHS
report and previous studies conducted in the surrounding area [5,19,20].

Our analysis indicates that utilization of skilled maternal care by individual women
depends on the joint effect of individual, household, communal and facility characteristics.
According to the intra-class correlation results, the contribution of unobserved communal
level characteristics, were 31% for antenatal care, 12% for delivery care and 25%
for postnatal care. In all the three intercept-only models, the contributions were
significant and indicated that determining association without the control of variables
at different levels would give a misleading result. This was also observed during
analysis where many of the significant associations disappeared when the effect of
clustering by kebele was controlled. Previous studies based on a similar analysis
showed consistent findings [12,13].

At the individual level, variables related to awareness and perceptions were found
to be much more relevant for skilled maternal service utilization. Women may get knowledge
on the importance of skilled maternal care in different ways such as previous exposure
to skilled maternal services, community based health educations, through community
media or due to their better educational status. In this study, women with at least
one antenatal care in previous pregnancies were significantly more likely, to use
skilled maternal care for all the three indicators of their recent pregnancy. The
positive effect of maternal service in the previous birth on current maternal care
was observed in different studies done elsewhere [12,21,22].

Having awareness about health facilities to get skilled professionals was a significant
predictor of both skilled antenatal and delivery care. The effect of awareness was
also observed in community-based interventions focusing on awareness creation. For
example, in Ethiopia, higher rate of household visits and awareness by health extension
and community health workers were associated with improved antenatal care use and
postnatal care visits [23]. Better educational status is believed to be an important factor for better awareness
and positive attitude related to maternal health service utilization. As expected,
skilled maternal care during pregnancy, delivery, and postnatal period increased steadily
with education. Women with secondary and above education were also significantly associated
with antenatal and delivery care by a skilled provider. Previous studies support our
findings [13,19,24,25].

One of the expected effects of knowledge about an issue is change on individual attitudes.
Women who have confidence on skilled providers and their care tend to use maternal
health services by a skilled provider. In our analysis, significantly higher utilization
rate of all skilled maternal health service indicators was observed among women who
perceive that health professionals are better and safer (prefer skilled providers)
for their maternity care. The implications of this finding is that community based
health education about the benefit of skilled maternal care by targeting women who
prefer non-skilled providers as well as improving the quality of care by providers
will bring a positive contribution for utilizing skilled maternal care.

The predictor birth order indicates that women tend to use skilled maternal care if
their birth is the first, and its significant effect is observed in antenatal and
delivery care. The variations observed in the odds ratios can be related with the
risk perception of women that varies overtime. Many women (48.3%) believe the first
pregnancy is risky compared with the next consecutive pregnancies. However, as the
number of pregnancies exceeds a certain limit, they start to think about another risk.
Because of this, many women (41.3%) believe that having too many births is risky for
a woman.

Women’s health seeking behavior is also influenced by the cost of maternity services
and their capacity to cover the expected expenses. For instance, a substantial proportion
of antenatal care users did not deliver or use postnatal care by a skilled provider.
On the one hand, maternity services, especially delivery care, are expensive. Studies
indicate that delivery care use among antenatal care users is highly correlated with
wealth [26]. On the other hand, delivery occurs suddenly. As a result, women have home birth
by non-skilled providers due to transportation problems and lack of preparation. The
positive contribution of better wealth status for all maternity service indicators
and its significant contribution to postnatal care are also observed in our analysis.
The study further evaluated the contribution of wealth indicators at kebele level.
Women living in kebeles with mixed (farming and trading) source of income were utilizing
significantly more skilled delivery and postnatal care than those living on farming
only. The finding indicates that the presence of different sources of income for covering
payments of transportation and other services contributed to the existence of higher
rate of expensive maternal services in the communities. In this study, payment requirement
at the time of delivery was an important barrier to delivery service by a skilled
provider. The negative effect of the cost of maternity services and the need for reducing
it was also observed in a study conducted in Tanzania. In the Tanzania study, standard
maternity services were costly. For most households, maternal health care could take
more than half of their annual consumption. The study further indicated that by subsidizing
maternity care, women, especially those in the lowest socio-economic category would
experience the greatest increase in service utilization [27]. The findings of our study and previous evidences imply that for better achievements
in the utilization of skilled maternal health services, there should be mechanisms
to reduce or avoid the costs of maternal services.

Another strong facility level predictor for skilled maternal care utilization was
the performance of health facilities. The presence of all the six signal functions
in the nearby basic essential obstetric care facility (health center) positively contributed
to the utilization of all indicators of skilled maternal services, and its effect
was significant on skilled attendance rate. Functioning obstetric facility means performing
the essential services for normal situations and complications and these services
should be available 24 hours a day and 7 days a week. The presence of all signal functions
reflects better performance (quality) of a health facility. Furthermore, the findings
of this study imply that improving the quality of care and monitoring facilities to
perform the expected function at their level will be one of the strategies to increase
the utilization rates of maternity care by a skilled provider.

Limitations

One of the limitations of this study was that women faced difficulties to differentiate
the type of skilled providers during interview. To reduce the problem, data collectors
gave further clarifications by collecting information on types of providers (doctor,
health officer, nurse, midwife, health extension worker or others) from health institutions
that gave services. Errors may occur in knowing the categories of health professionals.
However, there were no serious difficulties in categorizing service providers as skilled
or non-skilled, so it did not affect the interpretation of results. The potential
limitations expected during analysis of determinant factors were minimized.

Conclusions

Factors operating at individual and communal (kebele) levels play a significant role
in determining the utilization of skilled maternal health services, so controlling
unexplained variations of the higher level is very important for preventing misleading
associations. At the individual level, health-seeking behavior of a woman was more
dependent on her awareness and perception on skilled provider or care. Included communal
factors were relevant for both delivery and PNC. Health facility characteristics,
including performance (functionality) and cost of service were more important for
use of skilled delivery care than other maternity services. Improving community awareness
and perception on skilled providers and their care by targeting women who prefer non-skilled
providers and those who do not have any awareness is very important. Safe motherhood
education using the available communication networks in the rural communities (health
development army) and innovative informational campaigns are strategies to improve
the intended awareness and perceptions of women. Furthermore, ensuring the seamless
performance of basic essential obstetric care facilities (health centers) is also
very critical, especially for improving the rate of skilled attendance at birth.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors contributed equally during the process of proposal development. AG and
AW participated in data collection and analysis. AG prepared the draft. Then AW and
MF revised the drafts of the paper. All authors read and approved the final manuscript.

Acknowledgements

We are very grateful to Addis Ababa University for its technical and financial support.
We would like to extend our heartfelt thanks to Professor Henry Mosley for his valuable
comments starting from proposal development to the final manuscript preparation. We
would also like to thank all of the study subjects who participated in this study
for their commitment in responding to our interviews.

WHO: making pregnancy safer: the critical role of the skilled attendant. A joint statement
by WHO, ICM, and FIGO. Geneva: Department of Reproductive Health and Research, World Health Organization; 2004.